Provider Demographics
NPI:1902001027
Name:THIELBAHR, MARY L (MFT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:THIELBAHR
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 KANIKSU SHORES
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-6462
Mailing Address - Country:US
Mailing Address - Phone:208-263-5894
Mailing Address - Fax:208-263-8294
Practice Address - Street 1:20 BEARFOOT LANE
Practice Address - Street 2:
Practice Address - City:HERON
Practice Address - State:MT
Practice Address - Zip Code:59844
Practice Address - Country:US
Practice Address - Phone:406-847-5850
Practice Address - Fax:406-847-4242
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEDPSY901103TS0200X
IDLMFT2624106H00000X
CA18097106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool